Willows Of New Castle
1023 N 20th St, New Castle, IN 47362 · For profit - Corporation · 95 certified beds · (765) 529-9694 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (59%) runs well above the national median (45%)
- about 24% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 38.3% | 11.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.3% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.0% | 1.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 55.2% | 25.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.9% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 40.8% | 11.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 32.1% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.9% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.2% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.5% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.3% | 13.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 89.3% | 79.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.5% | 22.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.4% | 10.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.88 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.67 | 1.44 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
60.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 56 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 36.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 36 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 29% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.9%CMS range 49.2–71.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.2%CMS range 6.2–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 36.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 38.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.3%CMS range 3.2–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 95 beds and averages 60.2 residents a day — about 63% occupied, or roughly 35 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.43 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 3.95 on weekdays — 17% thinner on weekends. RN hours go from 0.45 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 59% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · Gcited before2024-01-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
A.) Based on observation, interview and record review the facility failed to adequate supervision during care and ensure two staff were providing care for a dependent resident resulting in the resident falling out of bed and sustaining 3 brain bleeds and 5 facial sutures (Resident B). B.) Based on observation, interview and record review the facility failed to have fall interventions of two assistive devices in place and failed to have a call light available for a resident who had sustained a fall with a fracture (Resident D). This affected 2 of 4 residents reviewed for accidents (Resident B and Resident D). Findings include: A.) During an interview with Resident B's Family member 1 on 1/22/24 at 1:21 p.m., indicated on 12/22/23 CNA 2 was attempted to provide incontinent care by herself and the resident rolled out of bed. When CNA 2 rolled the resident on her side, the resident grabbed the privacy curtain and fell out of bed. The family member indicated she visits the resident every day but she was not at the facility when this occurred it happened early in the morning, RN 1 called…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-03-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the stove hood was maintained in a clean sanitary manner. This deficiency had the potential to affected 58 of 58 residents who dine in the facility. Findings include:A tour of the kitchen was conducted with the Dietary Manager (DM) on 3/2/26 at 12:30 p.m. During the tour, the stove hood was observed. There was a griddle/stove underneath the left side of the hood. The hood had a significant amount of built-up, greasy debris on the back panels and sprinklers. The back panels appeared furry substance completely covering the panels and sprinklers. There was stringy debris of dark substance hanging from one of the sprinklers above the griddle/stove where food was prepared. The sticker on the front of the stove hood indicated it was last serviced on 11/26/25, and the next service was to be in May of 2026. An interview was conducted with the DM during the above observation on 3/2/26 at 12:30 p.m. She indicated they regularly used the griddle/stove underneath the hood, and she noticed the amount of built-up…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure a resident who received the wrong medication had a assessment completed, ongoing monitoring and vitals signs completed for 1 of 2 residents reviewed for quality of care (Resident B). Finding include:During an interview with Licensed Practical Nurse (LPN) 1 on 3/03/2026 at 1:05 p.m., the LPN indicated she witnessed RN 4 who no longer works at the facility administered Resident B one of Resident E's morning medication. This occurred months ago and LPN 1 was unsure of the date. The medication error was reported to the Director Of Nursing (DON) who no longer works at the facility. During an interview with the Nurse Practitioner (NP) on 3/4/26 at 2:37p.m., the NP indicated on 10/17/25 at 9:31 a.m., LPN 1 reported to her that Resident B had received Resident E morning medication of rivastigmine 3 milligrams (mg). The medication was used to treat dementia. The medication was not harmful to Resident B and the NP told LPN 1 to monitor the resident's vital signs and to observe for anxiety and tremors every shift for 24 hours.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to implement a splint for a resident with bilateral hand contractures as ordered by the physician for 1 of 1 resident reviewed for Range Of Motion (Resident 51). Finding include:During an observation on 3/02/2026 2:35 p.m., Resident 51 had bilateral hand contractures (a chronic hand condition where connective tissue in the palms of both hands thicken ) with no splints in place. During an observation on 3/04/2026 at 1:54 p.m., Resident 51 had bilateral hand contractures with no splints in place. During an observation on 3/05/2026 at 11:33 p.m., Resident 51 had bilateral hand contractures, the resident had a splint on his left hand and did not have a splint on his right hand. The splint was observed to be on the resident's bedside table. During an observation on 3/05/2026 at 12:46 p.m., Resident 51 was sitting in the dining room, the resident had a splint on his left hand and did not have one on his right hand. Review of the clinical record of Resident 51 on 3/5/26 at 12:55 p.m., indicated the resident's diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-06 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to adequately monitor and treat a resident's wandering behavior for 1 of 3 residents reviewed for dementia care and services. (Resident C) Findings include:The clinical record for Resident C was reviewed on 3/5/26 at 11:11 a.m. His diagnoses included, but were not limited to, dementia (mental decline) with agitation and anxiety. The nursing admission note, dated 2/17/26 at 4:10 p.m., by Licensed Practical Nurse (LPN) 7 indicated the resident was confused and combative. Within the first five minutes of arrival, he was up, refusing to wait on a physical therapy evaluation. He refused to follow staff direction. He moved over to his roommate's area of the room and started to move items around. He then had contact with the roommate. Verbal redirection by staff failed and Resident C became physical, he lashed out and stroke staff. The nursing note, dated 2/17/26 at 10:06 p.m., by LPN 7 indicated the resident was temporarily moved to another room, because he and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's ordered medication was available for administration upon admission to the facility for 1 of 3 residents reviewed for pharmacy services. (Resident C) Findings include: The clinical record for Resident C was reviewed on 3/5/26 at 11:11 a.m. His diagnoses included, but were not limited to, dementia (mental decline) with agitation and anxiety. The hospital discharge orders, dated 2/17/26, indicated staff were to administrator Resident C's Risperidone one time a day, three 0.5 mg tablets. The resident's next dose was due on 2/17/26 at 4:00 p.m. The resident was to receive Trazadone at bedtime, one 50 mg tablet. The resident's next dose was due on 2/17/26 at bedtime. The nursing admission note, dated 2/17/26 at 4:10 p.m., by Licensed Practical Nurse (LPN) 7, indicated the resident was confused and combative. Within the first five minutes of arrival, he was up, refusing to wait for a physical therapy evaluation. He refused to follow staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent a resident from eloping (leaving the facility without others being aware or giving permission) through the resident's room window for 1 of 3 residents reviewed for elopement. (Resident B) The deficient practice was corrected on 7-23-25, prior to the start of the survey, and was therefore past noncompliance. The facility had completed a physical assessment of the resident after the elopement, placed her on one-on-one direct supervision by facility staff, began an immediate investigation of the elopement, conducted interviews with facility staff regarding the elopement, conducted education with all staff on elopement policy and what to do in the event of an elopement, conducted an elopement drill, conducted an audit of all exit doors and alarms, ensured all windows were secured to not allow an opening more than six (6) inches and completed new assessments on all residents for wandering and elopement risks. Care plans were updated to reflect any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-14 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents, including a confidential resident, were treated with dignity during care for 2 of 3 residents reviewed for dignity. (Resident 9 and Confidential Resident) Findings include: 1. During an interview with Resident 9 on 3/10/25 at 1:26 p.m., they indicated it had taken an hour for anyone to come into her room when she turned her call light on to go to the restroom. Resident 9 indicated she had to wait so long for help, that she ended up having incontinent episodes of urine and feces in bed. Resident 9 indicated it made them feel bad and it upset them because it was unnecessary and could have been avoided. Resident 9 indicated this occurrence happens at least once a week. The clinical record for Resident 9 was reviewed on 3/11/25 at 12:09 p.m. Diagnoses included, but were not limited to, generalized anxiety disorder, muscle weakness, and chronic pain syndrome. The Quarterly Minimum Data Set (MDS) assessment, dated 2/5/25, indicated Resident 9 was cognitively intact. The quarterly MDS also indicated Resident 9…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide a bath and/or shower upon request and as care planned for 1 of 1 resident reviewed for bathing. (Resident 6) Findings include: The clinical record for Resident 6 was reviewed on 3/11/25 at 12:27 p.m. Diagnoses included, but were not limited to, stress incontinence and osteoarthritis of the left hand. During an interview with Resident 6 on 3/10/25 at 12:32 p.m., she indicated a couple months ago when she had COVID-19, she went several days without a bed bath or shower. Resident 6 indicated she asked staff for a shower, but they told her she could not have one because she had COVID-19 and would have to bathe her in her room. Resident 6 indicated she would have to go into her bathroom and wash up on her own. She indicated no bed baths were offered or given. She also indicated she takes her showers on Tuesdays and Fridays. During an interview with Licensed Practical Nurse (LPN) 2 on 3/12/25 at 11:47 a.m., they indicated when anyone was in isolation, they could take a shower, they are just taken last for the day due to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-14 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide routine dental care to residents when an inside source was not available for 1 of 3 residents reviewed for dental services. (Resident 2) Findings include: During an interview on 3/10/25 at 1:16 p.m., Resident 2 indicated she would like to see a dentist. Resident 2 indicated she had not seen the dentist in a long time. The clinical record for Resident 2 was reviewed on 3/11/25 at 12:05 p.m. Diagnoses included, but were not limited to, diabetes mellitus and cerebral infarction. The Annual Minimum Data Set (MDS) assessment, dated 1/8/25, indicated Resident 2 was cognitively intact for daily decision making. A Complimentary Dental Assessment consent was provided by the Administrator on 3/12/25 at 9:45 a.m. Resident 2 signed to give consent for dental services on 5/27/21. Resident 2's last dental exam provided by the Administrator, on 3/12/25 at 9:45 a.m., indicated Resident 2 had a dental exam on 9/9/22. During an interview with the Administrator on 3/12/25 at 9:55 a.m., she indicated the facility recently switched…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 2 of 2 residents diagnosed with Clostridium difficile infection (c-diff) were receiving care which included thorough and accurate assessments on a routine basis and the documentation of the assessments reflected the thorough assessments and resident status. (Residents B and C) Findings include: 1. The clinical record of Resident B was reviewed on 1-7-25 at 2:32 p.m. Her diagnoses included, but were not limited to, a history of urinary tract infections (UTI), systemic inflammatory response syndrome (SIRS), Alzheimer's disease and generalized muscle weakness. A hospital Discharge summary, dated [DATE], indicated she was diagnosed with a c-diff infection upon admission to the hospital on [DATE]. She returned to the facility on [DATE]. A review of the progress notes and Nursing Infection Charting ATB [antibiotic] daily assessments, dated 11-12-24 through 11-19-24, was conducted. The documentation failed to address the stooling status, such as the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · D2025-01-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 2 of 2 residents reviewed for urinary tract infections (UTI), received prompt treatment for complaints of dysuria (painful urination), urine culture and sensitivity reports be reviewed with the medical provider for accuracy related to the proper medications be ordered to treat the identified organisms, and their daily nursing assessments related to their diagnosis are thorough and accurate. (Resident B and D) Findings include: 1. The clinical record of Resident B was reviewed on 1-7-25 at 2:32 p.m. Her diagnoses included, but were not limited to, a history of urinary tract infections (UTIs), systemic inflammatory response syndrome (SIRS), Alzheimer's disease and generalized muscle weakness. 1.a. A review of the progress notes, dated 12-19-24 at 10:42 p.m., indicated a urinalysis with a culture and sensitivity (C&S) request was obtained from Resident B and sent to the lab for analysis on 12-20-24 at 5:58 a.m. An entry, dated 12-22-24 at 8:49…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to complete self-administration assessment for a resident that self-administers nasal spray for 1 of 1 resident reviewed for self-administration. (Resident 37) Findings include: The clinical record for Resident 37 was reviewed on 1/24/2023 at 11:30 a.m. The medical diagnosis included paranoid schizophrenia. A physician order for Resident 37, dated 12/7/2021, indicated for him to utilize a nasal spray that may be kept at the bedside and self-administered. An observation on 1/22/2024 at 11:05 a.m. indicated Resident 37 sitting in his recliner with a bottle of nasal spray on the table next to him. An observation and interview with Resident 37 on 1/22/2024 at 1:30 p.m. indicated that he utilized nasal spray for the last few years for congestion. The staff will order more when he runs low, but he is able to take care of giving himself the nasal spray. An interview with the DON on 1/25/2024 at 1:00 p.m., indicated that they did not have a self-administration assessment for Resident 37. A policy entitled, Medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide fresh water daily for 2 of 5 residents reviewed for hydration (Resident D and Resident 45). Findings include: 1.) During an observation on 1/22/24 at 1:45 p.m., Resident D was sitting in her recliner, there was no water pitcher in the room. Resident D indicated she has a faucet in the bathroom that she could get water out of. During an observation on 1/23/24 at 10:49 a.m., Resident D was sitting in her recliner with no water pitcher in her room. During an observation and interview on 1/23/24 at 1:12 p.m., Resident D and her family was visiting in the resident's room, the resident did not have any water available. Resident D's family searched the resident's room for her water pitcher and was unable to locate it. Resident D's family indicated they were unsure why the resident did not have water available. During an observation on 1/24/24 at 11:22 a.m., Resident D was sitting in her recliner with no water pitcher in her room. During an observation and interview on 1/24/24 at 1:06 p.m., Resident D was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide a resident with her choice and preference to when she went to bed for 1 of 2 residents reviewed for choices (Resident 56). Finding include: During an interview with Resident 56 on 1/22/24 at 12:52 p.m., indicated she did not feel like her right to choose was honored by the facility. The resident indicated the staff put her to bed at 7:00 p.m., and she preferred to go to bed at 9:00 p.m. or later,. The resident indicated she had talked to the facility about her preference about her bedtime, but they continue to assist her to bed at 7:00 p.m. Review of the Resident 56 on 1/25/24 at 2:00 p.m., indicated the resident's diagnoses included, but were not limited to, dementia, chronic kidney disease, depression, anxiety, osteoarthritis and history of falling. The activity interview and preferences for Resident 56, dated 12/12/23, indicated it was very important to choose her own bedtime. The resident preferred to go to bed after 9:00 p.m., 10:00 p.m., or later. The resident was a late night person. The plan of care for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and observations, the facility failed to promote a clean environment for Resident 35 by having dried fecal matter on his toilet and a dried brown substance on his bed linens for 1 of 2 residents reviewed for clean environment. Findings include: The clinical record for Resident 35 was reviewed on 1/25/2024 at 10:55 a.m. The medical diagnosis included Parkinson's disease and chronic respiratory failure. A Quarterly Minimum Data Set Assessment, dated for 12/28/2023, indicated that Resident 35 was cognitively intact. An observation and interview with Resident 35 on 1/22/2024 at 1:19 p.m. indicated that his bathroom had dried fecal matter on the toilet bowl and debris on the floor. He stated that they don't clean his bathroom often or always change his linens. An observations on 1/23/2024 at 1:08 p.m. of Resident 35's room indicated he continues to have dried fecal matter on his toilet bowl and dried brown substance on his linens. An interview with the Administrator on 1/25/2024 at 1:15 PM indicated that it is the housekeeping and nursing staff's responsibility to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and observation, the facility failed to submit a Discharge or Death Entry Minimum Data Set (MDS) assessment for Resident 48 and failed to accurately code specialized services for Resident 32 for 2 of 2 residents reviewed for MDS assessment accuracy. Findings include: 1. The clinical record for Resident 48 was reviewed on 1/25/2024 at 12:57 p.m. The last MDS assessment for Resident 48 was an admission MDS on 8/28/2023. A nursing progress note, dated 8/30/2023, indicated Resident 48 had passed away. No discharge/death MDS completed. 2. The clinical record for Resident 32 was reviewed on 1/23/2024 at 1:47 p.m. A MDS assessment, dated 11/2/2023, indicated Resident 32 was receiving specialized services of chemotherapy, oxygen therapy, suctioning, tracheostomy care, invasive and non-invasive ventilation, IV medications, dialysis, transfusion, hospice, and isolation. These services were not reflected in the medical record. An interview with the MDS nurse on 1/25/2024 at 2:00 p.m. indicated that the death/discharge assessment for Resident 48 was missed and the specialized…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to develop a care plan for 1 of 2 residents reviewed for skin tears. (Resident 111) Findings include: On 1/23/24 at 2:05 p.m., Resident 111 was observed sitting in a chair by the nurse's station on the South Unit. The area was above her right wrist, oval in shape and scabbed with a black color. Resident 111's record was reviewed on 1/25/24 at 1:32 p.m. and indicated diagnoses that included, but were not limited to, weakness, heart disease, and high blood pressure. An admission Minimum Data Set assessment, dated 1/9/24, indicated Resident 111 was severely impaired in cognitive skills for daily decision making, and had a skin tear. Progress notes, dated 1/3/24 at 11:30 a.m., indicated: resident in MDR (main dining room) playing noodle ball with peers, called to MDR and resident has 2 skin tears to her right forearm. 1cm (centimeter) x 1cm x 0.1cm and 0.5cm x 0.5cm x 0.1cm. Treatment applied to arm. On 1/29/24 at 1:36 p.m., the Administrator indicated they did not have a care plan for the skin tear. A policy for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to update a fall care plan for Resident 15 after his refusal to utilize careplanned fall interventions for 1 of 3 reviewed for fall care plans. Findings include: The clinical record for Resident 15 was reviewed on 1/24/2024 at 2:05 p.m. The medical diagnosis included dementia. A fall care plan, dated 3/24/2023, indicated interventions for Resident 15 of adding a sign to his walker for shows on 4/16/2023, call don't fall sign on the walker on 4/12/2023, and to utilize a walker instead of rollator on 4/12/2023. An observation of Resident 15's room on 1/22/2024 at 11:45 a.m. indicated he had a rollator in his room without signage, did not have a standard walker, and a call don't fall sign was on the closed bathroom door. An interview and observation on 1/25/2024 at 12:03 p.m. indicated that he did not have a standard walker in his room, did not have signage on his rollator, and had a call don't fall sign on the back of his bathroom door. Resident 15 indicated they tried to get him to use a walker and he turned it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to complete weekly nursing assessments per physician order for 3 of 3 residents reviewed for potential impaired skin integrity. (Resident 18, Resident 32, and Resident 38) Findings include: 1. The clinical record for Resident 18 was reviewed on 1/26/2024 at 1:02 p.m. The medical diagnosis included peripheral vascular disease. A Quarterly Minimum Data Set (MDS) Assessment, dated 12/14/2023, indicated that Resident 18 was at risk for developing pressure areas, had one stage three pressure area, and received pressure ulcer care, surgical wound care, and applications to ointments/medications to the feet. A physician order for Resident 18, dated 12/12/2023, indicated to complete Weekly Nursing Assessment V2 every Tuesday. A review of the medical record indicated that Resident 18 had Weekly Nursing Assessments completed on: 1/23/2024, 1/2/2024, 12/26/2023. Assessments were not able to be located for 12/19/2023, 1/9/2024, or 1/16/2024. 2. The clinical record for Resident 32 was reviewed on 1/23/2024 at 1:47 p.m. A MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to accurately complete weekly nursing assessments to reflect pressure areas for 2 of 2 residents reviewed for pressure areas (Resident 19 and Resident 32) Findings include: The clinical record for Resident 18 was reviewed on 1/26/2024 at 1:02 p.m. The medical diagnosis included peripheral vascular disease. A Quarterly Minimum Data Set (MDS) Assessment, dated 12/14/2023, indicated that Resident 18 was at risk for developing pressure areas, had one stage three pressure area, and received pressure ulcer care, surgical wound care, and applications to ointments/medications to the feet. A physician order for Resident 18, dated 12/12/2023, indicated to complete Weekly Nursing Assessment V2 every Tuesday. A rounding wound care provider had seen Resident 18 for skin areas, including a pressure area to the right heel, on 1/12/2024, 1/17/2024, and 1/24/2024. During the 1/24/2024, the pressure area was resolved. The medical record indicated that Resident 18 had Weekly Nursing Assessment completed on 1/23/2024. The assessment did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure one resident's bed rail had safe dimensions. This affected 1 of 1 resident reviewed for accident hazards related to bed rail use. (Resident 21) Findings include: On 1/22/24, at 1:18 p.m., Resident 21 was observed sitting in her recliner watching TV. Attached to the open side of her bed was a one quarter width bed rail, and the lower section of the bed rail had a large opening between the lower bars of the bed rail. On 1/22/24, at 1:32 p.m., the bed rail was measured by the Administrator, and the Director of Nurses was also present. The inside dimensions of the lower part of the bed rail measured eight and one half inches by fifteen inches. The Director of Nurses said Resident 21 didn't walk, so they could remove the bar, and Resident 21 indicated she wanted them to leave it alone. On 1/23/24, at 10:40 a.m., Resident 21 was observed in bed watching TV and the bed rail was in place on the bed. On 1/24/24, at 9:40 a.m., Resident 21 was observed in bed, the bed rail remained on the open side of the bed.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HENRY COUNTY MEMORIAL HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2012 |
| DYNES, SHELDON | Individual | CORPORATE DIRECTOR | — | since 01/01/2012 |
| PIDGEON, JOHN | Individual | CORPORATE DIRECTOR | — | since 01/01/2012 |
| SHORE, MARION | Individual | CORPORATE DIRECTOR | — | since 01/01/2012 |
| WARE, DEBORAH | Individual | CORPORATE DIRECTOR | — | since 08/27/2021 |
| RING, BRIAN | Individual | CORPORATE OFFICER | — | since 08/01/2022 |
| NEW CASTLE IN OPCO, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/13/2025 |
| FRANKEL, ISRAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/08/2025 |
| PATTON, ELIZABETH | Individual | ADP OF THE SNF | — | since 01/13/2025 |
| REIS, JAMES | Individual | ADP OF THE SNF | — | since 01/13/2025 |
CMS files one row per role, so the 12 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 24% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155089. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.